BC Balance and Dizziness Disorders (BADD) Society 2016 Professional Education Funding (January 1 December 31, 2016)

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1 BC Balance and Dizziness Disorders (BADD) Society 2016 Professional Education Funding (January 1 December 31, 2016) Applications due: June 30, 2016 Concept of Award The purpose of this education fund is to provide funding for educational opportunities that aim to improve the diagnosis, treatment, and/or quality of life of individuals with vestibular disorders. AWARD $10,000 will be awarded annually. Each applicant may apply for a maximum of $2,500 ($2,500 is the maximum per application and total lifetime funding from the BC Balance and Dizziness Disorders Society). Eligibility All applicants must be actively engaged in clinical practice (hospital or private practice) in British Columbia. Applicants may be from any healthcare profession, such as General Practitioner, Otology Resident, or Physical Therapist. Members of the BADD Medical Advisory Committee or the BADD Board or their immediate families are ineligible for this award. Application Requirements Electronic (typed) submissions are limited to one per candidate per year. Hand-written applications will not be accepted. Upon completion of the award, the applicant will be required to submit a brief Final Report on how the educational key learning was disseminated and a Budget to the BC Balance and Dizziness Disorders Society board. A brief lay summary of the educational opportunity and key leanings will be published in the quarterly newsletter of the BC Balance and Dizziness Disorders Society. Successful applicants may be requested to present to the BADD members at a general meeting. Applications (PDF or Word) should be ed to: info@balanceanddizziness.org All applications must be received no later than June 30, 2016 to be considered eligible for the award. Awards will be reviewed by members of the scientific advisory board and elected board members of BC Balance and Dizziness Disorders Society. The award winners will be notified by no later than Aug. 31, Funding will be available to successful applicants beginning Sept. 1, In addition to the Application form below, please also provide the following Attachments: 1. Curriculum Vitae (CV) Please include: a) Educational background, b) Employment history, c) Professional Activities, d) Professional Membership, e) Certification/Awards, f) Educational/Training opportunities, g) Publications/Presentations, and any information relevant to the current application Please use 11-point font (minimum) on letter-size paper with 2.5 cm margins and single line spacing. Your name should appear in the header on the right hand side of each page. Attach as either a MS Word or PDF file. 2. Receipts related to Application Original receipts required to receive payment. If not available, a detailed online statement of account from the institution may be acceptable providing it bears your name, institution name, payment date and amount. Reimbursement for funding up to the maximum awarded value. Please detail/itemise receipts attached: Page 1 of 5

2 2016 RESEARCH AWARDS APPLICATION: Due June 30, Name of Applicant (Last, First, Initials): Titles (PhD, MSc, PT, OT, MD): Last Degree completed (date): Healthcare Profession (e.g., General Practitioner, ENT resident, Physical Therapist): Home Address: City: Province: Postal Code: Phone: 2. Name of Employer/Place of Clinical Practice: Address: Work Setting: (e.g., acute, rehabilitation, ambulatory clinic): Professional Role/Title: City: Province: Postal Code: Phone: 3. Title of Educational Opportunity (Course/Program Name): Institution: Location: Dates (include start and end dates): Indicate if part-time or full-time: 4. Total Funding Requested (maximum $2,500): $ 5. Please indicate which best describes this Educational Training/Opportunity application type: Short Course / Seminar / Training Workshop Registration Accredited Certification Course / Post-Basic Certificate Online education courses Fees related to Educational/Training Opportunity (e.g., travel, accommodation) Other: 6. Have you, or will you be, receiving funding/reimbursement from any other source? Yes / No If yes, provide details (from whom, when, and dollar amount(s)): 7. How did you hear about the BC Balance and Dizziness Disorders Society Education Fund? Page 2 of 5

3 8. Summary of educational/training opportunity Enter in the space provided below (maximum length: 150 words) 9. Significance of Educational Opportunity to people with dizziness/imbalance: How has/will this educational/training opportunity contribute to quality care and services for BC clients/residents/patients living with dizziness and imbalance? Enter in the space provided below (maximum length: 200 words) 10. Significance of Educational Opportunity to your career: How has/will this educational/training opportunity contribute to your career objectives? Enter in the space provided below (maximum length: 150 words) Page 3 of 5

4 11. Dissemination of Information: What is your plan for sharing your learning with your colleagues and patients? When and how will his happen? Enter in the space provided below (maximum length: 200 words) 12. Budget Category (incurred Amount and expected) Tuition Fees $ Description and Brief Justification Travel Fees $ Accommodation Fees $ Books/Educational Material Fees $ Other $ Total Funding Requested (up to a $2500 maximum) $ 13. Please indicate if you have previously received Education Funding from the BC Balance and Dizziness Disorders Society: Yes / No If yes, provide details (when and dollar amount(s)): Page 4 of 5

5 Certification by Applicant : I certify that to the best of my knowledge the details provided in this application form and any supporting documentation are true and complete. : I confirm that my professional registration is in good standing with my professional college. : I understand that if I receive Educational Funding that I will share this information with colleagues and people living with dizziness and imbalance as described in question 11. Signature of Applicant Name (please print) Date / / Certification by Employer/Place of Clinical Practice : I certify that: I am aware of the application set out by the applicant; To the best of my knowledge all details on this application form are true and complete; This institution supports this application and if successful it will provide basic support in dissemination of learning; The project can be accommodated within the general facilities in this institution and that sufficient working and office space is available for any proposed additional staff. Signature of Employer Name (please print) Date / / Submit completed and signed application forms along with original receipts and confirmation of course/programme registration by to: info@balanceanddizziness.org Page 5 of 5